State of Wyoming



STATE OF WYOMING ) IN THE DISTRICT COURT

) ss

COUNTY OF ________________ ) _______________ JUDICIAL DISTRICT

Plaintiff:____________________________, ) Civil Action Case No. __________

(Print name of person filing) )

)

vs. ) CONFIDENTIAL

)

Defendant:__________________________. )

(Print name of other parent)

_______________________________________________________________________________

CONFIDENTIAL

FINANCIAL AFFIDAVIT

W.S. (20-2-308 _______________________________________________________________________________

A financial affidavit must be completed by each parent. You must attach copies of your tax returns and W-2 forms for the most recent two years and a copy of the total amount of wages you have earned so far this year. Parents who are self-employed must supply verified income and expense statements from their business for the two most recent years.

THE UNDERSIGNED, ___, hereby swears or affirms, (Print Your Name)

under penalty of perjury, that the following answers are correct and complete.

1. Your Name: (First, Middle, Last) ______________________________________________

Gender: Male Female

2. Your Present Address: _______________________________________________________

City, State, Zip Code: _______________________________________________________

How long have you resided at this location? ______________________________________

Your Mailing Address (if different from above) ___________________________________

City, State, Zip Code: _______________________________________________________

3. Your Home Phone Number: (___) _____________________________________________

Your Cell Phone Number: (____) ______________________________________________

A Message Phone Number: ( )

4. Your Social Security Number is: ______________________________________________

5. Your Date of Birth is:

6. Your Education is: ________years of high school; _________years of college;

________ years of trade school; _______ years other (list training)

7. List your degree(s) or certificate(s):

8. List all child(ren) involved in this matter:

|Child’s Name | |Birth Date |Social Security No. |Does this child live with you?|

| |Sex | | | |

| | M F | | | Yes No |

| | M F | | | Yes No |

| | M F | | | Yes No |

| | M F | | | Yes No |

| | M F | | | Yes No |

Additional sheets of paper are attached (if needed)

9. List YOUR minor children (not named above) who live with you:

|Child’s Name |Birth Date |Social Security No. |

| | | |

| | | |

| | | |

| | | |

| | | |

Additional sheets of paper are attached (if needed)

10. List YOUR minor children (not named above) who do not live with you but for whom YOU are court-ordered to pay child support:

|Child's Name |Birth Date |Social Security No. |

|Court and Date of Order |Support/Month |Arrears (Amount Past Due) |

|Child's Name |Birth Date |Social Security No. |

|Court and Date of Order |Support/Month |Arrears (Amount Past Due) |

|Child's Name |Birth Date |Social Security No. |

|Court and Date of Order |Support/Month |Arrears (Amount Past Due) |

|Child's Name |Birth Date |Social Security No. |

|Court and Date of Order |Support/Month |Arrears (Amount Past Due) |

Additional sheets of paper are attached (if needed)

11. Do you owe back child support (arrears) in this case? If so, how much? $____________.

12. List any income-qualified state or federal benefits that your child(ren) receive (POWER, Medicaid, Kid Care, Title 19, General Assistance, Food Stamps, Supplemental Security Income, etc.):

| CHILD'S NAME |BIRTH |STATE |TYPE OF |

| |DATE | |BENEFIT |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

Additional sheets of paper are attached (if needed)

13. Are you currently: Employed Self-Employed Unemployed

If you are employed, please provide the following:

Job No. 1:

Employer’s Name: __________________________________________________________

Employer’s Address: ________________________________________________________

City, State, Zip Code: _______________________________________________________

Employer’s Phone: _________________________________________________________

Your Occupation: __________________________________________________________

Your Hourly Wage or Monthly Salary: _________________________________________

Job No. 2:

Employer’s Name: _________________________________________________________

Employer’s Address: _______________________________________________________

City, State, Zip Code: _______________________________________________________

Employer’s Phone: _________________________________________________________

Your Occupation: __________________________________________________________

Your Hourly Wage or Monthly Salary: _________________________________________

Job No. 3:

Employer’s Name: _________________________________________________________

Employer’s Address: _______________________________________________________

City, State, Zip Code: _______________________________________________________

Employer’s Phone: _________________________________________________________

Your Occupation: __________________________________________________________

Your Hourly Wage or Monthly Salary: _________________________________________

Add additional sheets of paper if necessary to list additional jobs.

How many hours do you work each week?

Job No. 1: Job No. 2: Job No. 3

Regular Regular Regular

Overtime Overtime Overtime

Total Total Total

How often do you receive overtime compensation? ________________________________

How often are you paid:

Job No. 1: Job No. 2: Job No. 3

weekly weekly weekly

every two weeks every two weeks every two weeks

twice per month twice per month twice per month

monthly monthly monthly

annually annually annually

Date of your last salary increase or decrease: _____________________________________

14. List all income you have received for the last 12 months:

|Income Source |Monthly Amount |Income Source |Monthly Amount |

|Gross Wages** |Job 1 - $ __________ |Annuity |$ |

| |Job 2 - $__________ | | |

| |Job 3 - $__________ | | |

|Unemployment |$ |Spousal Support |$ |

|Workers’ Compensation |$ |Contract Receipts |$ |

|Social Security Benefits (Excluding |$ |Rental Income |$ |

|SSI) | | | |

|Retirement |$ |Fringe Benefits/Bonuses |$ |

|Interest/Dividend Income |$ |Profit (Loss) from Self-Employment |$ |

|Reimbursements |$ |Other |$ |

|Veterans’ Disability |$ |Other |$ |

**Gross Wage - Monthly amounts are calculated by multiplying weekly amount by 52 and dividing by 12; multiplying bi-weekly (every two weeks) amounts by 26 and dividing by 12; and multiplying semi-monthly (i.e., paid on the 1st and 15th) amounts by 24 and dividing by 12.

Additional sheets of paper are attached (if needed)

15. IF YOU ARE EMPLOYED: Please complete list and calculate the following:

A. Gross income: $ per month

(Amount of income from all sources before deductions)

B. Federal Income Tax: $____________ per month

C. State Income Tax: $ per month

D. Social Security Tax: $ per month

E. Medicare Tax: $ per month

F. Mandatory Retirement/Pension: $ per month

G. Premium Paid for Child(ren)’s Health Insurance: $ per month

H. Current Child Support Paid for Other Children: $ per month

I. Total Mandatory Deductions: $ per month

J. Net Income (line A minus line I): $ per month

K. Income Tax Filing Status:

L. Number of Dependents Claimed for Tax Purposes:

Please provide copies of pay-stubs for all payroll deductions.

Attach copies of your tax returns and W-2 forms for the most recent two years and a copy of a cumulative earning statement(s) for the current year

16. IF YOU ARE SELF-EMPLOYED: Please list the following:

A. Gross income : $ per month

*amount of income from all sources before deductions

B. Federal Income Tax: $ per month

C. State Income Tax: $ per month

D. Social Security Tax: $ per month

E. Medicare Tax: $ per month

F. Unreimbursed Business Expenses: $ per month

G. Premium Paid for Child(ren)’s Health Insurance: $ per month

H. Current Child Support Paid for Other Children: $ per month

I. Total Mandatory Deductions: $ per month

J. Net Income (line A minus line I): $ per month

K. Income Tax Filing Status:

L. Number of Dependents Claimed for Tax Purposes:

Attach verified income and expense statements from your business, copies of your personal and business tax returns, and 1099 forms for the most recent two years.

17. List your work experience for the last three years:

| COMPANY AND |DATES |JOB |SALARY |REASON YOU LEFT |

|LOCATION |FROM - TO |DESCRIPTION/TITLE |OR WAGE | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

Additional sheets of paper are attached (if needed)

18. Has anyone been ordered to provide health insurance for the child(ren) involved in this case, or is there any other medical provision in an existing court order? YES NO

If yes, please list who is ordered to provide insurance:

Are the children currently covered by insurance? YES NO

If yes, please list who is providing the insurance:

If you are currently providing insurance for your children, you must provide current written proof from your insurance carrier verifying the names of the actual person(s) covered under your policy.

Is health insurance available for the minor child(ren) through your employment?

YES NO

If yes, how much is the monthly premium to cover ONLY the minor child(ren) on the policy?

$________________

19. Attach the following to this Confidential Financial Affidavit:

If Employed:

Copies of my last two years income tax returns;

Copies of my W-2 Forms for the last two years; and

Copies of statements of earnings from each of my employers showing cumulative pay for this year.

If Self-Employed:

Verified income and expense statements for the business for the two most recent years; and

Copies of my last two years personal income tax returns.

Copies of my last two years business income tax returns.

PERJURY STATUTE

20. Wyoming Statute § 6-5-301 (Perjury) provides:

(a) A person commits perjury if, while under a lawfully administered oath or affirmation, he knowingly testifies falsely or makes a false affidavit, certificate, declaration, deposition or statement, in a judicial, legislative or administrative proceeding in which an oath or affirmation may be required by law, touching a matter material to a point in question.

(b) Perjury is a felony punishable by imprisonment for not more than five (5) years, a fine of not more than five thousand dollars ($5,000.00), or both.

OATH

I have read and understand the provisions of the above perjury statute. I affirm that this Confidential Financial Affidavit (including attachments) contains a complete disclosure of my income from all sources and that the representations made herein concerning my income are accurate to the best of my knowledge. I am aware that the court may punish as perjury any materially false statements knowingly made with intent to defraud or mislead.

DATED this _____ day of ________________, 20____.

______________________________________

Your Signature

(Sign only in front of Notarial Officer or Court Clerk)

JURAT

STATE OF _____________ )

) ss.

COUNTY OF ___________ )

Subscribed and sworn to before me on this _____ day of ________________20____, by ________________________________.

WITNESS my hand and official seal.

______________________________

Notarial Officer

My Commissions Expires: ___________________

CERTIFICATE OF SERVICE

I certify that on (date) the original of this Confidential Financial Affidavit was filed with the Clerk of District Court; and, a true and accurate copy of this document was served on the other party by Hand Delivery OR Faxed to this number

OR by placing it in the United States mail, postage pre-paid, and addressed to the following:

(Print Plaintiff/Plaintiff’s Attorney’s Name and Address)

TO: ______________________________________

______________________________________

______________________________________

Your signature

Print name

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PERSONAL INFORMATION

INCOME & EXPENSE INFORMATION

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